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Case
03

BEHAVIOURAL PROBLEM TEENNAGER

FAMILY MEDICINE SYSTEM

FAKULTAS KEDOKTERAN UNIVERSITYAS PADJADJARAN

2014 - 2015
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Block title : Family Medicine

Case title : Behavioral problems
Case theme : Biopsychosocial approach

Case description:
Most parents of teenagers are familiar with common behavioral problems, such as staying out too late,
dressing to shock or refusing to put down their cell phones. But if teen's behavior issues seem
disproportionate to those of his peers, he/she may be suffering from a psychiatric disorder.

Parents are often disturbed by the appearance and continued presence of certain kinds of behavior
problems. An immediate response is to attempt every possible means to eliminate the troublesome
behavior from the child’s repertoire on the notion that once ingrained, such behaviors become
permanent and habitual. Some parents turn to professionals, such as paediatricians, family physicians,
child psychiatrist, child psychologists, and early childhood education specialists, for guidance in dealing
with these problems.

Case objective for the student:

By the end of the session the students will be able to explain:
1. Genogram
2. Parenting skills (review)
3. Family APGAR
4. Functional and dysfunctional family
5. Health care maintenance for teenager (screening and counselling)
6. Early detection of behaviour problems in child and adolescent
7. Assessment of behaviour problems in child and adolescent in primary health care
8. Different diagnosis of behavioural problems in child and adolescent
9. Management of behaviour problems in child and adolescent in primary health care
10. Prevention of behavioural problems in child and adolescent
11. Conduct disorder:
a. Risk factors (bio-psycho-social)
b. Diagnosis
c. Differential diagnosis
d. Management (bio-psycho-social)
e. Prognosis
12. Bioethical aspect of disclosure patient’s diagnosis to third parties (school/teachers for
comprehensive management, and law institution for patient behaviour that breaks the
law such as theft and vandalism)
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CASE SYNOPSIS

Asep, a 14-year-old boy, brought by his mother to a clinic with cuts on his right
arm which is happened 3 hours ago due to a ‘tawuran’ fight. Since 3 years ago
Asep begin to have behavioural problems. He often argues with his parents and
teachers, refuses to comply with their order, bullies, threatens, and annoys other
students, runs around with a bad group ‘gang motor’ who are probably engaged
in vandalism and theft, involves in “tawuran” fights, lies, stolen money and
valuable goods, stays out at night despite parental prohibitions, run away from
home overnight, and truant from school. Asep comes from a dysfunctional
family. His diagnosed as conduct disorder + laceration at right forearm region.
The doctor repairs his injury, gives a psycho education and parenting skills to his
mother, and refers Asep to a psychiatrist to overcome his psychiatric problems.

Reference for the tutor and student:

1. Lee Gan, Azwar.A, Wonodirekso. Family Medicine Practice. Singapore, 2004. section 3 chapter 1
pp 24-5, 42- 8, 60-2, 457-475, Section 4
2. Mc.Daniel S. Campbell TL. Hepworth J. Lorenz A. Family-Oriented Primary Care
3. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition,
2007, Lippincott Williams & Wilkins
4. WHO, mhGAP (Mental Health Gap Action Programme) Intervention Guide for mental,
neurological and substance use disorders in non-specialized health settings, 2010
5. WHO, Prevention of mental disorders, effective interventions and policy options, 2004

Tutorial 1 page 1

Asep, a 14-year-old boy, brought by his mother to a clinic with cuts on his right arm
which is happened 3 hours ago.

1. Identify the problems!

2. What are your hypotheses?
3. What further information do you need?

TUTOR GUIDE

Problems:

1. Cuts on the right arm which is happened 3 hours ago.

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Hypotheses:

1. Laceration at right arm region

Tutorial 1 page 2
Asep says that the injury was due to accidental knife-cut when he was playing with his
friends. His mother looks confused and says ‘No, that’s not true, he got injured in a
fight when …!’ but Asep interrupts her by shouts “Come on Mom, the most important
thing is the doctor will help me with this injury, don’t be fussy!” His mother shouts
back “Hey, can’t you stop shouting at me and be polite for just one time?” Asep shouts
back to her mother and they shout at each other until the doctor stops them. Asep
looks impatient and cannot sit still, demanding his injury be dealt with immediately so
he can leave.
Medical history:
Asep has no history of a bleeding disorder or other medical illness. His last tetanus
booster was 4 years ago. There are no known allergies to, or current use of, any
medications. He had no numbness, weakness, loss of function, or any significant pain.
Physical examination:
His blood pressure is 110/70, pulse is 80, respirations are 20, and temperature is 37°C.
Examination of his right arm reveals a 2.5-cm laceration of the flexor surface of the
mid forearm. There is some dried blood over the wound. There is no other abnormality
found in physical examination.

1. Identify the problems!

2. Is your hypothesis change?
3. What further information do you need?

TUTOR GUIDE

Learning objectives:

1. Recognize behavioural problems in child and adolescent (early detection)

2. Assessment of behavioural problems in child and adolescent
Problems:

1. 2.5-cm laceration of the flexor surface of the mid forearm

2. Got injured accidentally by knife-cut
3. Looks impatient and cannot sit still (hyperactivity/tension)
4. Interrupt and shout at his mother about the cause of injury (impulsivity/aggression,
hostile behavior)
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Hypotheses:

1. Uncomplicated 2.5-cm laceration of the left forearm

2. Behavioural problems

Tutorial 1 page 3
The doctor then gives his mother a change to talk. His mother says that Asep
begun to has behaviour problem 3 years ago and he has been more erratic in his
behavior recently. He ignores parents and teachers order. He often argues with
his father. He rarely attends school and usually preferring to play with peers.
When he does go to school, he frequently walks around in the class to disturbing
other students and often gets into trouble for answering back his teacher. He is
very rarely doing his schoolwork. Every time his mother tries to talk to him, he
will shouts angrily at her, tells her to mind her own business.

1. Identify the problems!

2. Is your hypothesis change?
3. What further information do you need?

Learning objectives:

1. Differential diagnosis of behavioural problems in child and adolescent

Problems:

1. Begun to has behavioural problems since 3 years ago and became more erratic recently
(onset at 10 years old)
2. Ignores parents and teacher order (inattention/ negativistic, hostile, and deviant
behaviour)
3. Often argues and opposites his father (impulsivity/ negativistic, hostile, and defiant behavior)
4. Answering back his teacher (impulsivity/ negativistic, hostile, and deviant behaviour)
5. Frequently truant from school (violation of rules)
6. Frequently walks around in the class to disturbing other students (hyperactivity/
negativistic, hostile, and deviant behaviour)
7. Rarely doing his schoolwork (inattention/ negativistic, hostile, and deviant behaviour)

Hypotheses:

1. Attention Deficit and Hyperactivity Disorder

2. Oppositional deviant disorder
3. Conduct disorder
4. Delinquency
5. Uncomplicated 2.5-cm laceration of the left forearm
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Tutorial 1 page 4

According to his mother, Asep got injured in a fight with students from another school
in a ‘tawuran’. Recently, Asep often has a ‘tawuran’ fight and gets hurt. He also runs
around with a bad group ‘gang motor’ who are probably engaged in vandalism and
theft. He often leaves the house for several days without parent’s permission. Once he
tries to hit his father because his father refused to buy him a motorcycle. Last year he
got suspense from school for threatening behaviour and bullied other students. His
family often lose money and valuables goods at home, and many times they found that
he who takes it.

When the doctor turns to Asep, he smiles without regret and replies “I am a young
man, doc, everybody in my age do that”

Psychiatric examination:

Uncooperative, defensive

Attention: normal

Mood: slight irritability

Content of thinking:
1. Identify some antisocial urges and impulses
the problems!
2. Iscomplete
Insight: your hypothesis
denial ofchange?
illness.
3. Please explain what factors can influence the development of Asep’s behaviour
 Judgment : poor social and test judgment
problems!
4. What ofurther information do you need?
5. Should the doctor reporting patient behaviour that breaks the law (theft and vandalism) to
the police institution?
Learning objectives:
1. Sign and symptoms of conduct disorder
2. Bioethical aspect of disclosure patient’s diagnosis to third parties (law institution for
patient behaviour that breaks the law such as theft and vandalism)
Problems:

1. Often has ‘tawuran’ fights (aggression, destruction of property)

2. Runs around with a bad group ‘gang motor’ who are probably engaged in vandalism and
theft (aggression, destruction of property, theft)
3. Often leaves the house for several days without parent’s permission (violation of rules)
4. Once Asep tries to hit his father because his father refused to buy him a motorcycle
(aggression)
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5. Got suspense from school for threatening behaviour and bullied other students
(aggression)
6. Steals money and valuable goods from his family (theft)
7. Has no regrets for his behaviour

Hypotheses:

1. Conduct disorder
2. Uncomplicated 2.5-cm laceration of the left forearm

Tutorial 1 Page 5

Family History
Asep is a first son with one sister and one brother. His father is a truck driver. He
is very grumpy and punitive. His mother is a textile factory worker who goes to
work early in the morning and come home late in the evening. They both rarely
getting involves with their child, poorly monitoring their child's whereabouts, not
pay attention to what peers their child is associating with, and give a harsh and
inconsistent discipline practices toward them. They both have a small income.
Genogram

S,65 R,60 S, 59

I, 40 N, 35

Asep, 14 T, 12 Y, 10

Family APGAR score : 4

Asep is diagnosed as Conduct disorder + laceration at right forearm region

1. Explain the genogram of Asep’s family!

2. Explain the Family APGAR!
3. Could Asep’s family’s parenting style influence his current behaviour problems? Please
explain!
4. How to diagnose conduct disorder?
5. Explain the risk factor of conduct disorder!
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6. Explain the course and prognosis of conduct disorder!

7. What is your management plan for this case?
8. How to prevent behavioural problems in child and adolescent?
8. Explain the health care maintenance for teenager! (screening and counselling)

Problems:

1. Father is very grumpy and punitive

2. Mother goes to work early in the morning and come home in the evening.
3. Parent rarely getting involves with their child
4. Parent poorly monitoring their child's whereabouts and peers
5. Parent give a harsh and inconsistent discipline practices toward child
6. Parents have small income
7. APGAR scores 4

Learning Objectives:

1. Genogram
2. Family APGAR
3. Functional and dysfunctional family
4. Parenting skills (review)
5. Risk factor of conduct disorder
6. Diagnosis and different diagnosis of conduct disorder
7. Course and prognosis of conduct disorder
8. Management of conduct disorder
9. Management of child and adolescent behavioural problems in primary health care
10. Prevention of child and adolescent behavioural problems
11. Health care maintenance for teenager (screening and counselling)
Epilogue
After informed consent, the doctor repairs his injury. The doctor gives a psycho
education and parenting skills to his mother. After several discussions with the
doctor, his mother agreed to bring Asep to a psychiatrist to overcome his
psychiatric problems. -case ended-

TUTOR GUIDE
Early detection of behavioral problems in child and adolescent
1. Excessive inattention and absent-mindedness, repeatedly stopping tasks before
completion and switching to other activities
2. Excessive over-activity: excessive running around, extreme difficulties remaining seated,
excessive talking or fidgeting
3. Excessive impulsivity: frequently doing things without forethought
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4. Repeated and continued behaviour that disturbs others (e.g. unusually frequent and severe
temper tantrums, cruel behaviour, persistent and severe disobedience, stealing)
5. Sudden changes in behaviour or peer relations, including withdrawal and anger
Different diagnosis of behavioural problems in child and adolescent
6. Attention Deficit and Hyperactivity Disorder
7. Oppositional deviant disorder
8. Conduct disorder
9. Delinquency
Prevention of conduct disorders, aggression and violence
The most successful preventive interventions to reduce the risk of aggressive behaviour and
conduct disorders focus on improving the social competence and prosocial behaviour of children,
parents, peers and teachers. These interventions are developed in tandem with a consensus
developmental model for conduct problems with its emphasis on social interaction between
children, caregivers and peers. New intervention attempts inform the model, and new cross-
sectional and longitudinal research findings inform innovative intervention attempts.
Universal interventions
Universal interventions that have been found to successfully impact on conduct problems are all
school-based, and include classroom behaviour management, enhancing child social skills and
multimodal strategies including the involvement of parents.

Classroom behaviour management programmes attempt to help children better meet the social
demands of the classroom through the overt encouragement of desired behaviours and the
discouragement of undesired behaviours. Effective programmes have resulted in decreased
student conduct problems (e.g. decreased disruptive behaviour, decreased aggression) and better
relationships among students and between students and teachers.
Child social skills programmes attempt to provide children with cognitive skills that may help
them cope better with difficult social situations. Commonly, skills related to listening, empathy,
interpersonal problem-solving and conflict and anger management are taught, usually within the
classroom context.
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These programmes have been found to positively impact on cognitions related to problem-
solving and reduce impulsive behaviours, at least for up to one year following
intervention. Children and teachers report decreased conduct problems.
Multimodal interventions tend to either include multiple interventions within the school setting
or multiple interventions across settings, such as combining a school-based child social skill
intervention with parent management training. Multimodal programmes are intended to
simultaneously provide children and their caregivers with the skills needed to effectively
encourage the development of prosocial behaviour patterns. These interventions have showed
lower rates of aggression in the playground and decreases in a variety of conduct problems,
including bullying, theft, vandalism, self-reported conduct problems and first arrests.
Selective interventions
Selective interventions designed for a variety of settings have been found to be effective in
preventing conduct problems, including prenatal and/or early childhood programmes and school
or community-based programmes. Prenatal and/or early childhood programmes usually attempt
to improve the skills of parents to nurture, support and teach their children’s prosocial behaviour
patterns and/or to develop the social skills of children. These programmes have shown a decrease
in risk factors for conduct disorders, such as maternal smoking during pregnancy and child abuse
and neglect, and decreases in child conduct problems during adolescence, including reductions in
violence and police arrests. School or community-based programmes for selective child
populations at risk have successfully targeted child social and problem-solving skills and/or
parent management skills, resulting in a decrease in negative parent–child interactions and
teacher ratings of conduct problems at school.
Indicated interventions
Indicated interventions to prevent conduct disorder focus on children who have been identified
by teachers and/or parents as clearly displaying significant conduct problems. Such programmes
have shown decreases in conduct problem displays through several middle school years as
reported by teachers and the children themselves. An effective example that includes universal,
selective and indicated components is Fast Track (Conduct Problems Prevention Research
Group, 2002). In this programme children are identified in kindergarten. Throughout their school
years, the children participate in a wide variety of interventions, including social and problem-
solving skills training (i.e. PATHS), play sessions with prosocial peer partners and academic
tutoring. Parents participate in parent management training groups and parents and children
participate in planned skill training activities. Families also receive regular home visits and case
management assistance. Results of a randomised trial after the first three years of intervention
have indicated that children in the Fast Track programme displayed lower levels of conduct
problems as rated by both teachers and parents.
Conduct disorder
 Risk factors of Conduct disorder
No single factor can fully account for a child's antisocial behavior and conduct disorder.
Rather, many biopsychosocial factors contribute to development of the disorder.
Parental Factors
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Harsh, punitive parenting characterized by severe physical and verbal aggression is

associated with the development of children's maladaptive aggressive behaviors. Chaotic
home conditions are associated with conduct disorder and delinquency. Divorce itself is
considered a risk factor, but the persistence of hostility, resentment, and bitterness
between divorced parents may be the more important contributor to maladaptive
behavior. Parental psychopathology, child abuse, and negligence often contribute to
conduct disorder. Sociopathy, alcohol dependence, and substance abuse in the parents are
associated with conduct disorder in their children. Parents may be so negligent that a
child's care is shared by relatives or assumed by foster parents. Many such parents were
scarred by their own upbringing and tend to be abusive, negligent, or engrossed in getting
their own personal needs met.
Sociocultural Factors
Socioeconomically deprived children are at higher risk for the development of conduct
disorder, as are children and adolescents who grow up in urban environments.
Unemployed parents, lack of a supportive social network, and lack of positive
participation in community activities seem to predict conduct disorder.
Psychological Factors
Children brought up in chaotic, negligent conditions often express poor modulation of
emotions, including anger, frustration, and sadness. Poor modeling of impulse control and
the chronic lack of having their own needs met leads to a less well-developed sense of
empathy.
Neurobiological Factors
In some children with conduct disorder, a low level of plasma dopamine β-hydroxylase,
an enzyme that converts dopamine to norepinephrine, has been found. This finding
supports a theory of decreased noradrenergic functioning in conduct disorder. Some
conduct-disordered juvenile offenders have high serotonin levels in blood. Evidence
indicates that blood serotonin levels correlate inversely with levels of the serotonin
metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and that
low 5-HIAA levels in CSF correlates with aggression and violence.

Neurologic Factors
Frontal resting brain electrical activity has been hypothesized to reflect the ability to
regulate emotionality. children with higher reported externalizing behaviors had
significantly greater relative right frontal EEG activity during rest compared with
children with little or no reported aggressive behavior.
Child Abuse and Maltreatment
It is widely accepted that children chronically exposed to violence, especially those
receiving repeated physical or sexual abuse that starts at a young age are at high risk for
behaving aggressively.
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Children who are exposed to caregivers who are exposed to violence are also
likely to demonstrate disruptive and aggressive behaviors themselves. Children exposed
as witnesses to maternal abuse or recipients of abuse themselves may be reticent to
verbalize their experiences because of direct threats from the abusive adult, and therefore
may instead demonstrate their feelings through aggressive and destructive behaviors.
Comorbid Factors
ADHD, CNS dysfunction or damage, and early extremes of temperament can predispose
a child to conduct disorder. Propensity to violence correlates with CNS dysfunction and
signs of severe psychopathology, such as delusional tendencies. Longitudinal
temperament studies suggest that many behavioral deviations are initially a
straightforward response to a poor fit between a child's temperament and emotional
needs, on one hand, and parental attitudes and child-rearing practices, on the other.
 Diagnosis and Clinical Features.
The relation of conduct disorder to oppositional defiant disorder is still under debate.
Historically, oppositional defiant disorder has been conceptualized as a mild precursor of
conduct disorder, which is likely to be diagnosed in young children at risk for conduct
disorder. Children who progress from oppositional defiant disorder to conduct disorder
do maintain their oppositional characteristics, but some evidence indicates that the two
disorders are independent. Many children with oppositional defiant disorder never go on
to have conduct disorder, and when conduct disorder first appears in adolescence, it may
be unrelated to oppositional defiant disorder. The main distinguishing clinical feature of
the two disorders is that in conduct disorder, the basic rights of others are violated,
whereas in oppositional defiant disorder, hostility and negativism fall short of seriously
violating the rights of others.

DSM-IV-TR Diagnostic Criteria for Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major
age-appropriate societal norms or rules are violated, as manifested by the presence of three
(or more) of the following criteria in the past 12 months, with at least one criterion present
in the past 6 months:
Aggression to people and animals
1. often bullies, threatens, or intimidates others
2. often initiates physical fights
3. has used a weapon that can cause serious physical harm to others (e.g., a bat, brick,
broken bottle, knife, gun)
4. has been physically cruel to people
5. has been physically cruel to animals
6. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion,
armed robbery)
7. has forced someone into sexual activity
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Destruction of property
8. has deliberately engaged in fire setting with the intention of causing serious damage
9. has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
10. has broken into someone else's house, building, or car
11. often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
12. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery)
Serious violations of rules
13. often stays out at night despite parental prohibitions, beginning before age 13 years
14. has run away from home overnight at least twice while living in parental or parental
surrogate home (or once without returning for a lengthy period)
15. is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or
occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality
disorder.
Code based on age at onset:
Conduct disorder, childhood-onset type: onset of at least one criterion characteristic of conduct
disorder prior to age 10 years
Conduct disorder, adolescent-onset type: absence of any criteria characteristic of conduct
disorder prior to age 10 years
Conduct disorder, unspecified onset: age at onset is not known

Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct
problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between mild and
severe•
Severe: many conduct problems in excess of those required to make the diagnosis or conduct
problems cause considerable harm to others

 Differential Diagnosis of conduct disorder

1. Oppositional defiant disorder
Hostility and negativism fall short of seriously violating the rights of other
2. Mood disorders
Often present in those children who exhibit irritability and aggressive behavior
3. Major depressive disorder and bipolar I disorder
Impulsive and aggressive behavior is not as severe

 Management of conduct disorder

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1. Psychotherapy
Includes individual or family therapy, parenting classes, tutoring, and emphasis of special
interest. Multimodality treatment programs that use all the available family and
community resources are likely to bring about the best results in efforts to control
conduct-disordered behavior. Multimodal treatments can involve the use of behavioral
interventions in which rewards may be earned for prosocial and nonaggressive behaviors,
social skills training, family education and therapy, and pharmacologic interventions.
Treatment strategies for young children that focus on increasing social behavior and
social competence are believed to reduce aggressive behavior. No treatment is considered
curative for the entire spectrum of behaviors that contribute to conduct disorder, but a
variety of treatments may be helpful in containing symptoms and promoting prosocial
behavior.

Families in which psychopathology or environmental stressors prevent parental understanding of

the techniques may require parental psychiatric evaluation and treatment before making such an
endeavor.
When a family is abusive or chaotic, the child may have to be removed from the home to

benefit from a consistent and structured environment. School settings can also use
behavioral techniques to promote socially acceptable behavior toward peers and to
discourage covert antisocial incidents.
Behaviorally based individual psychotherapy targeting problem-solving skills with
appropriate rewards can be useful, because children with conduct disorder may have a
long-standing pattern of maladaptive responses to daily situations.
2. Pharmacotherapy
Antipsychotics such as haloperidol, risperidone, and olanzapine help control severe
agressive and assaultive behavior. Lithium is helpful for some aggresive children with or
without comorbid bipolar disorders. The selective serotonin reuptake inhibitors (SSRIs),
such as fluoxetine, sertraline, paroxetine, and citalopram, have been used in an attempt to
diminish impulsivity, irritability, and lability of mood, which often occur with conduct
disorder.
 Course and prognosis of conduct disorder
In general, the prognosis for children with conduct disorder is most guarded in those who
have symptoms at a young age, exhibit the greatest number of symptoms, and express them
most frequently. This finding is true partly because those with severe conduct disorder seem
to be most vulnerable to comorbid disorders later in life, such as mood disorders and
substance use disorders. It stands to reason that the more concurrent mental disorders a
person has, the more troublesome life will be. A recent report found that, although assaultive
behavior in childhood and parental criminality predict a high risk for incarceration later in
life, the diagnosis of conduct disorder per se was not correlated with imprisonment.

A good prognosis is predicted for mild conduct disorder in the absence of coexisting
psychopathology and the presence of normal intellectual functioning.
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Family Dynamic And Health

Family dynamic may be defined as the interactions and relationships among the individual
members of a family. For example, family dynamics can describe how one individual
perceives another family member's attitude about his role in the family unit, the effect that
perception has on the way those two family members relate the one another and consequences
for the other family members based on that interaction.
Family dynamic reflect and influence the physical, mental and spiritual health of the
individuals in family.
According to Mosby's Medical Dictionary published in 2009, family dynamics is defined as
the forces at work within a family that produce particular behaviors or symptoms. It is the
way in which a family lives and interacts with one another that creates the dynamic. And that
dynamic, whether good or bad, changes who people are, it burrows into their psyche,
ultimately influencing how they view and interact with the world outside of their family.
An understanding of the dynamics helps the attending physician to diagnose the disease and
dis-ease in the patient sitting in his consultation room and to recognize the factors that may
help or retard recovery of this patient.
Family Structure
Family structure is one-way family dynamics are perceived. Factors like the number of
children, parents and others, the biological connection or lack thereof between a parent and
child and the age rank and difference among children in a household will play a part in how
family dynamics are characterized.
Hierarchy
Hierarchy reflects how power or authority is distributed within the family. General cultural
consensus places parents above children in the family hierarchy. Single parents are
encouraged to recognize that they have greater authority than their children, and parents, even
when separated, are encouraged to share authority for decision making with each other.
Boundaries
Boundaries help define different functional subgroups in the family, (e.g., the marital
subgroup, the sibling subgroup, the grandparents, etc.). In respectful interactions, families
recognize the boundaries around sub- groups, allowing, for example, parents to have a
private relationship that is not undermined by children or grandparents.
Family Values
The values of the family unit and each family member's personality affect the family
dynamic and can often be a primary source of conflict. Ethnic, religious and cultural
background and values are often assumed to be a shared experience for members of the
same family, particularly in the eyes of a parent. When another family member disagrees
with or has life experiences opposed by these standards, it can put a strain on the family
dynamic, with the traditionally complying members experiencing disobedience, betrayal or
concern for their well-being.

The family member opposing the standards often feels like she is not being listened
to, ignored, expected to change, disgracing the family or experiencing "black sheep
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syndrome." Even after initial conflicts (if any) are resolved, this difference in values will
still in some way affect family dynamics. This has particularly been a concern for families
where the country of origin of a parent and child are different and the child is accustomed to
a different set of social and cultural values.
Influence
There are many different influencing factors (or combinations thereof) that can alter the
family dynamic--for better or for worse--beginning with the relationship between the
parents. Influences can also include the number of children a family has, an absent parent,
alcoholism, chronic illness, disability, substance abuse, physical abuse, death, social-
economical status, divorce, unemployment, family values, parenting practices and the list
goes on.
Role
Just as in any other situation where people are expected to coexist, family members, most
especially children, begin to take on particular roles within the family. These roles could
very well be the due result of their family dynamics, and have little to do with conscience
choice. Depending upon their position within the family, including their birth order, the roles
quickly become an indelible part of the given dynamic. In many dysfunctional families,
especially those experiencing serious issues such as alcoholism, you will find the perennial
peacekeeper, the scapegoat/ irresponsible child, the family hero/the responsible child, the
care-taker and the mascot. Each role has a very specific duty to its family, and it is nearly
impossible for a child to separate himself from it.
Family role selection is the conscious or unconscious assignment of complementary roles to
members of a family. These roles function to maintain the family system (e.g., mother is the
breadwinner and the problem solver; grandmother is the nurturer). During health crises,
family members seem to adopt identifiable roles (e.g., caretaker, or the one who “can’t
handle bad news”).
Alliance 

An alliance is a positive relationship between any two members of a system (e.g., a mother
and father cooperating together).
Coalition 

A coalition is a relationship between at least three people in which two collude against a
third (e.g., a parent and a child siding against another parent).
Family Assessment
Family assessment is a continuous activity based on theoretical concepts and tools that
easily can be integrated into daily practice.
Family assessment begins with the first visit and is a continuous process. As in any medical
assessment, clinicians can assess the “anatomy,” the development, and the functioning of a
family. The anatomy of a family is the membership, which is easily obtained through a
genogram.

Family development is noted by the family member’s ages and developmental stages, and
functioning is assessed through history and observation of family process.
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The Genogram (Family Anatomy)

The family genogram (family anatomy) is an essential tool for busy practitioners to recall
information about family member’s names, relationships, and overall structure.
Genograms can have a biomedical focus, as a way of organizing family medical and genetic
information, and still set a biopsychosocial tone to the encounter and the overall practice.
Genogram information should include names, ages, marital status, former marriages,
children, households, significant illnesses, dates of such traumatic events as deaths, and
occupations. It can also include emotional closeness, distance, or conflict between members,
significant relationships with other professionals, and other relevant information. Genogram
construction may reveal trans-generational family patterns of loss, dysfunctional emotional
patterns, or common medical problems. A quick glance at the genogram prior to a visit is a
reminder of names and family relationships.

Example genogram:
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Family APGAR
This is a five-item questionnaire designed to elicit the patient’s perception of the current state of
his family relationships, and serves as a rapid screening instrument for family dysfunction.
APGAR is the acronym derived from the initial letters of the phrase:
Adaptation is the capability of the family to utilize and share inherent resources
Partnership is sharing of decision making. This measures the satisfaction attained in solving
problems by communicating.
Growth refers to both and emotional growth. This measures the satisfaction of the availability
freedom of change
Affection is how emotions like love, anger and hatred are shared between members. This
measures the members’ satisfaction with intimacy and emotional interaction that exist in the
family.
Resolve refers to how time, space and money are shared. This measures the members’
satisfaction with the commitment made by other members of the family.
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